Endotracheal intubation is a mandatory competency for many healthcare professionals (HCPs), such as physicians, neonatal nurse practitioners and respiratory therapists responsible for neonatal resuscitation. Neonatal intubation is a complex skill that requires critical procedural knowledge and experience. If the procedure is performed by an inexperienced HCP, life-threatening complications may arise. The American Academy of Pediatrics' (AAP) Neonatal Resuscitation Program (NRP) recommends a 30-second limit for intubation attempts, and studies have revealed that pediatric residents had a high failure rate of attempted intubation.
HCPs require training and practice to execute precise, controlled insertion of a laryngoscope to achieve successful endotracheal tube placement. HCP training involves rigorous and repetitive practice as they conduct intubation on actual patients sporadically and infrequently. Intubation training is often performed using plastic models or manikins that lack realistic anatomic features. Subject matter experts (SMEs), e.g., experienced physicians, have a failure rate of 0.1% while less experienced HCPs, such as residents, have failure rates of 25-33%. Failure to use the laryngoscope effectively may lead to damage of soft tissues (e.g., the larynx or esophagus) or result in life-threatening changes in heart rate and/or blood pressure. Training may be hindered by the lack of realistic simulators and quantitative tools to evaluate the necessary competency for successful airway intervention.
In the United States and Canada, endotracheal intubation is initially taught to all trainees through participation in the AAP'S NRP. NRP provides a standardized approach to the technical aspects of neonatal resuscitation, which includes the intervention of endotracheal intubation. This approach to learning the neonatal intubation procedure consists of a review of literature, didactic instruction, skills training using patient simulators and observation of the intervention as performed by a more experienced colleague at the bedside. The trainees then perform the actual technical procedure on patients under the supervision of senior colleagues.
Furthermore, the successful completion of NRP does not ensure that HCPs have acquired the necessary competence to perform neonatal resuscitation. Clinical supervision is required for HCPs to assume responsibility for any portion of neonatal resuscitation including the intervention of intubation. This creates a significant challenge for trainees, such as pediatric residents, to become competent in the intervention of neonatal intubation because the current guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) for Pediatrics have restricted the amount of intensive care experience obtained during pediatric residency. These training guidelines state that the neonatal intensive care curricula must be structured to train residents to perform delivery room resuscitation and stabilization of infants.
Residents are expected to learn procedural skills applicable to general pediatrics including endotracheal intubation. Although the ACGME requires competence in endotracheal intubation as part of the pediatric residency training, no definition for procedural competence is outlined in the common program requirements. In addition, these training guidelines specify that experience should be graduated so that residents build and maintain skills throughout their training program. However, the training guidelines limit the residents' experience and exposure to neonatal resuscitation by restricting neonatal and pediatric intensive care rotations to a maximum of six months. Given these restrictions, residents complete training with a small number of hands-on experiences in neonatal intubation. Consequently, simulation-based training for acquiring neonatal intubation skills may offer greater opportunity than ‘real-life’ clinical experiences for teaching, learning and refinement of relevant knowledge and development of skills.
The methods of training HCPs have changed and it is no longer acceptable to practice intubation technique on infants who have died. Other training models of intubation have included animals and patient simulators. With technological advancements, high fidelity manikin-based simulators are most commonly used in neonatal resuscitation training programs to provide a risk-free environment for trainees to develop procedural skills and decision-making under highly controlled circumstances. NRP instructors present case scenarios that create environmental fidelity as would be experienced in the delivery room. However, neonatal patient simulators lack the cues necessary to engender realistic responses on the part of the HCPs using them.
All simulators have limitations in replication of physiology and anatomical variability. Although existing simulation-based training outcomes have been shown to provide trainees with increased confidence in treating neonates with acute physiologic changes, this confidence and/or perceived skill set may not translate to improved clinical practice. As such, knowledge is not necessarily transferred adequately into clinical practice using the currently available simulation methodologies and technologies.
Although successful neonatal endotracheal intubation is highly dependent on the HCP's technique, existing training methods and technologies have not provided quantitative evaluation of the mechanics (e.g., force and torque) of successful neonatal intubation. The forces exerted on the airway of a neonatal patient simulator are unlikely to reflect those of a safe and effective intubation of a real human neonatal patient. Training devices in use today do not provide sufficient feedback to trainees regarding the force they use during neonatal/infant intubation. As a result, training to a set of objective, quantitative standards for intubation mechanics is not part of existing curriculum for HCPs who perform this procedure. Because assessment of these skills is highly subjective (i.e., based on the opinion of an instructor), trainees may experience difficulty acquiring and maintaining the skills necessary for successful neonatal endotracheal intubation.